Iso pts for pregnant and chemo-receiving HCWs

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In another thread, there was a lot of tension re: iso pts w/ pregnant HCWs. I googled. Here is what I found from one source.

Chapter 109 - The Pregnant Healthcare Worker

Stanley A. Gall, MD
Professor of Obstetrics, Gynecology and Women's Health
University of Louisville School of Medicine
Louisville, KentuckyAPIC recognizes and appreciates the contributions made to this chapter by prior authors.ABSTRACT

Following Standard Precautions (i.e., consider all body fluids except sweat potentially infectious and use personal protective equipment [PPE] when exposure to blood or body fluids is anticipated), as recommended by the Centers for Disease Control and Prevention (CDC) for all healthcare workers (HCWs), will protect pregnant HCWs against most infectious agents to which they may be exposed. However, because some infectious agents can cause congenital syndromes in the fetus when primary infection is acquired during pregnancy, there are additional concerns in pregnant or potentially pregnant HCWs. For practical purposes, immunologic function is normal during pregnancy, and an otherwise healthy woman is not considered to be an immunocompromised host. Pregnancy does not increase the risk of acquisition of infections, and, for most infectious agents, clinical manifestations of infections are no more severe in pregnant women than in those who are not pregnant. In view of the routes of transmission and ubiquity of some infectious agents (e.g., cytomegalovirus [CMV]), restricting pregnant women from caring for patients with potentially transmissible infections is considered only for patients infected with parvovirus B19 and for patients with respiratory syncytial virus (RSV) infections who are receiving ribavirin aerosol. Because patients with vaccine-preventable diseases should be cared for by only immune HCWs, it is especially important for women contemplating pregnancy to obtain the needed vaccines before conception. Similar to nonpregnant HCWs, susceptible pregnant HCWs should be restricted from contact with patients with rubeola, rubella, varicella, and smallpox. Much anxiety among pregnant HCWs results from misinformation concerning epidemiology and transmission of infectious agents. The emphasis must be on eduction of all HCWs of childbearing age, ideally before pregnancy, or at least as soon as pregnancy is diagnosed. It is important to note that the incidence of CMV and parvovirus infection is not increased among HCWs compared with other occupations, especially day care center workers and school teacher.

I know we all cover for our pregnant and chemo-receiving colleagues. I have too. However, as nurses we must also be open to the scientific facts tempering our visceral reactions.

As for chemo-receiving nurses, I only have anecdotal evidence. A coworker was receiving chemo, she never missed a day of work, and she took iso patients. She knew her white count was very high d/t neutrophil-stimulating drugs, she followed all PPE protocol, and she was fine.

This is NOT to say that all pregnant or chemo-receiving nurses need to go about their business as if they aren't different from other nurses. Every situation is different, and each affected nurse needs to make her own decision (and also deal with the fallout from it). But, as I stated previously, we need to know the facts vs. reacting according to our feelings.

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In addition to infection control measures for health care workers in general, the CDC guideline addresses the following special categories of workers:

Pregnant employees. The CDC recommends that employee health services should counsel pregnant women and women of childbearing age regarding the risk of transmission of particular infectious diseases (e.g., cytomegalovirus, various forms of hepatitis, herpes simplex viruses, HIV, parvovirus, rubella). If acquired during pregnancy, such diseases may have adverse effects on the fetus, whether the infection is acquired in nonoccupational or occupational environments. Information should be provided to such women on standard and transmission-based precautions appropriate for each infection. Women should not be routinely excluded, on the basis only of their pregnancy or intent to be pregnant, from the care of patients with particular infections that have potential to harm the fetus, according to the CDC.

and OSHA rerecommends....

Pregnancy and breastfeeding

Is it safe for nurses to administer chemotherapy if they are pregnant or trying to conceive?

The issue of whether nurses should prepare or administer chemotherapy or care for patients who are receiving chemotherapy while trying to conceive or while pregnant or nursing is one of the more controversial topics in chemotherapy administration. Several resources may be helpful.
ONS took a stance on this issue in the ONS Chemotherapy and Biotherapy Guidelines and Recommendations for Practice (2009).
Address HD handling around pregnancy. Even when all recommended precautions are used, the potential for exposure cannot be completely eliminated. Therefore, an additional level of protection is suggested for those most vulnerable to the reproductive and developmental effects of HDs. Employers should allow employees who are actively trying to conceive or are pregnant or breastfeeding to refrain from activities that may expose them and their infant to reproductive health hazards such as chemical, physical, or biologic agents. Alternate duty that does not include HD preparation or administration must be made available upon request to both men and women in the aforementioned situations or who have other medical reasons for not being exposed to HDs. The employee has the responsibility of notifying the employer of the specific situation (e.g., pregnancy, preconception, breastfeeding). The American College of Occupational and Environmental Medicine (1996) provides guidelines for managing reproductive hazard management (p. 82).
ONS’s Safe Handling of Hazardous Drugs, (2nd ed.)(Polovich, 2011) does an excellent job of reviewing the current data related to exposure and related risks, as well as precautions to lower risk.
The American Society of Health-System Pharmacists (ASHP) Guidelines on Handling Hazardous Drugs also addresses this issue in the “Background” section: "Two controlled surveys have reported significant increases in a number of symptoms, including sore throat, chronic cough, infections, dizziness, eye irritation, and headaches, among nurses, pharmacists, and pharmacy technicians routinely exposed to hazardous drugs in the workplace. Reproductive studies on health care workers have shown an increase in fetal abnormalities, fetal loss, and fertility impairment resulting from occupational exposure to these potent drugs" (p. 40).
The ASHP guidelines state the following in the “Alternative Duty and Medical Surveillance” section. "Such safety programs must be able to identify potentially exposed workers and those who might be at higher risk of adverse health effects due to this exposure. Because reproductive risks have been associated with exposure to hazardous drugs, alternative duty should be offered to individuals who are pregnant, breast-feeding, or attempting to conceive or father a child. Employees’ physicians should be involved in making these determinations" (p. 50).
The Occupational Safety and Health Administration (OSHA) Technical manual, Section VI: Chapter 2, “Controlling Occupational Exposure to Hazardous Drugs” doesn't make specific recommendations, but does address potential risks in some detail. For instance, III.C. ”Human Data at Therapeutic Levels” states the that “[m]any HD's are known human carcinogens, for which there is no safe level of exposure.” Furthermore, the report states the following.
Numerous case reports have linked chemotherapeutic treatment to adverse reproductive outcomes.7,88,91,98 Testicular and ovarian dysfunction, including permanent sterility, have occurred in male and female patients who have received CD's either singly or in combination.14 In addition, some antineoplastic agents are known or suspected to be transmitted to infants through breast milk.79"
In section VI.A. “Reproductive Issues,” the report states the following.
The examining physician should consider the reproductive status of employees and inform them regarding relevant reproductive issues. The reproductive toxicity of hazardous drugs should be carefully explained to all workers who will be exposed to these chemicals, and is required for those chemicals covered by the HCS. Unfortunately, no information is available regarding the reproductive risks of HD handling with the current use of BSC's and PPE. However, as discussed earlier, both spontaneous abortion and congenital malformation excesses have been documented among workers handling some of these drugs without currently recommended engineering controls and precautions. The facility should have a policy regarding reproductive toxicity of HD's and worker exposure in male and female employees and should follow that policy.
The OSHA manual addresses reproductive issues in other sections as well.
The National Institute for Occupation Safety and Health (NIOSH) Preventing Occupational Exposures to Antineoplastic and other Hazardous Drugs in Healthcare Settings contains detailed information about safe-handling practices, including handling recommendations while pregnant or trying to become pregnant.

Most employers prefer to exclude these nurses to prevent issues and lawsuits later. I would hope co-workers would be understanding with the pregnant coworkers.

Despite precautions, bugs and hazardous drugs are still occasionally passed to the nurse. While this may not directly affect her health, a pregnant nurse is taking a risk with a developing human being within who can be susceptible to many things that mom's body may not blink at. While we rigorously held to appropriate precautions on my oncology ward, it was policy that pregnant nurses not work with patients who were actively on chemo, nadiring or that had an infectious disease.

What if there was a chemo spill? Or a spill of fluids from an infectious patient onto the nurse? Or a needlestick?

Is it unlikely? Yes. But most nurses and managers that I know would much rather take extra precautions to safeguard a developing life than hope that all goes as it's supposed to. We all know what happens to the best-laid plans on occasion.

When I was getting chemo, I was working in oncology. After one of my treatments, my counts really tanked, as in WBC less than1000, ANC 0.057, HGB 6. We didn't have any iso pt. at the time, but I know my co-workers would have protected me. There would have been no reason for me to risk my health.

This is really a 'Catch 22'. In the US, there is a ton of case law so there is no longer any debate on the issue. Pregnancy is not a disability nor is it a 'protected class', so employers are not required to make any sort of accommodations. Since this is the case, if an employer does make special arrangements for a pregnant worker, they can be sued for discrimination by any other worker who did not receive the same special treatment..... srsly.

In a workforce that is still roughly 80% female, this is a perpetual issue. If/when a pregnant nurse is no longer able to safely perform all of her job duties, the plan should be either to work with her employer for a transfer to a different job or opt for FMLA.

The CDC however posts suggestions to this.....and OSHA rerecommends....Most employers prefer to exclude these nurses to prevent issues and lawsuits later. I would hope co-workers would be understanding with the pregnant coworkers.